Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

that's us. Live now. Good evening, everyone. Thank you very much for coming along to this evening's webinar. Lucas and I have been running a series and we're running it on behalf of Edinburgh Students Surgical Society. And this is an undergraduate surgical teaching series aiming to teach students, particularly the University of Edinburgh, but also more widely, um, elements of the undergraduate curriculum catered towards surgery. And this evening we're very grateful to have Saskia along to teach us about gallstones. Um, Saskia is a surgical trainee who is currently undertaking a year as a medical education fellow with NHS Lothian ahead of her application to hire surgical training. Um, she enjoys sharing her passions for surgery through undergraduate teaching and is a regular tutor at our surgical skills club as well. And she's looking forward to discussing gallstone disease with us this evening. So, without further a do, I will hand over to Saskia. That's great. Thank you, Beatrice and Lucas for organizing. And I appreciate this is a re, um, scheduled events. Unfortunately, I had some serious tech problems last time, so thanks all for joining again. So, gallstones. This is a topic I really enjoy discussing and certainly as a student, I don't think I had very much understanding of what they were and what problems can cause. I'm just going to turn my camera off to help with my signal. Um, and hopefully you can still hear me. If there's any problems, just pop questions in the chat, Um, and look as if you're able to move the slide on. That's great, so aims of session. So what we have is kind of short contents of what we're going to achieve tonight. So my other hat is as an anatomy teacher and demonstrator, which is where I might have met some of you guys. I was then asked me research fellow for Edinburgh uni a couple of years ago, so you can't understand gallstones and the problems they can cause without understanding the Billary Anatomy and again, To me as a student, this was a bit of a unknown territory. I could never really get my head around, build build ups and hepatic duct, so I'll hopefully clear that up for you tonight. We'll understand what the gallbladder does because we like to chop them out when there's gallstones there and they cause problems. But it's important to know what does the gallbladder actually do And can you live without it? We're going to also have a think about how gallstone disease might present, and it can present in a number of ways. And I've got a number of cases to show you tonight, um, that you will either have seen in practice or you will see in the future. Well, think about how gallstones can cause complications and how those arise and how we treat them. And then the last thing we will do is go through a variety of case based discussion's where I welcome your involvement. I've been told that you can't speak by the microphones tonight, so do try and warm your fingers up so you're ready to type my finger freezing cold. So, um, we want to get as many different thoughts from you whether you're preclinical, clinical or FY. I'm keen to hear all of your opinions. Next slide, please. So, uh, there we are. So let's start with Hillary Anatomy now. Normally, I'm a bit more cruel, and I will give you an image that has no labels on it. But I've been quite kind, given that it's nearly Christmas, and I have given you a nice demonstration of the biliary tree anatomy. So unfortunately, not me, that's driving the slides tonight, so I I don't have a mouse to wiggle, but I will talk you from top to bottom so you can see this is as working the right upper quadrant of the abdomen. So that's an important quadrant to be thinking about tonight in the gray shadowed kind of area that is your liver and on the right hand side of the screen is the patient's left hand side on our left is the patient's right. So that's another thing that's really important to remember in anatomy or with your patient's. Um, just be mindful of those opposites because they can really cause problems. If you get them mixed up, you can see that we've got branches that are inside the liver. So we've got our left hepatic duct and a right hepatic duct, and those are going to come together to form what is called the common hepatic duct. So hepatic, referring to the liver and common because we've got both left and right sides of the liver draining bile into that common hepatic duct. you might see it shortened as CHD. Underneath the liver. You've got a little green bag, and that is your gallbladder. We'll be talking a bit more about what that does, but you can see that that joins the common hepatic duct by a duct called the cystic duct. Now cystic usually refers to the bladder, but in this case, the gall bladder has of this. It's a It's a different type of bladder from your urinary bladder, but that kind of word cystic. Think of bladder whenever you hear that. But of course this case, it's the gallbladder when those two pipes come together. So you got your cystic duct and the common hepatic you get a very famous duct, which most surgeons will all be able to tell you about which the common bile duct. Okay, We all were quite fearful of this duct because it can get in the way of our surgeries sometimes, and any injury to this can cause big problems. So this is the common bile duct, and as the name suggests, this is where Bio will drain from the liver. Once it's been made and will come down into that pink tube, there which is your second part of your duodenum. So the anatomy here is really quite important to know. And it's a common question for either anatomy, MCQ s or postgraduate exams. But you've got your common bile duct coming down into the Judean. Um, you can see there's a little what's called an ampulla that will contain a small sink term. So your body is actually able to control that opening of the common bile ducts, allowing bile to come down into your duodenum, and then we'll talk about later about what the bile actually does. So try and keep this picture in your head whenever you're thinking about gallstones. Um, and this is definitely going to help you understand the problems that they can cause. So if we can move onto the next slide and we'll talk about about what the gallbladder does, I like using these little pictures and anyone that's heard me talk about gallstone disease before we'll know that I like these little pictures. Um, they're a bit silly, but they're quite good at explaining things in reminding, um, the can functions of various parts of the body. I forget the I think it's awkward. Yeti they've got lots of them. If you want to look them up so you can see there's the liver handing little buckets of bile to the gallbladder. And that's because when you're in a period of fasting, so first thing in the morning when you've not yet had your breakfast or late at night. And once you've already digested your dinner, your bile is always constantly dripping down the pipe work that you've seen. But what it will do is I'll go into your gallbladder, and that is where the gallbladder starts to work on it. And it's concentrating the bile, draining water from it, essentially to make it a little bit more gloopy and a little bit more effective from what it's what it's going to do. And you can see there that it's really important for helping to break down and absorb fats. So when you then eat something, so if you have a fatty meal, your stomach and duodenum will start to release a chemical called Cholecystokinin. And that is another really important name to remember, because if you break it up, coal assist refers to the gallbladder, and Keenan will think about kinetics and movement dynamic movement. So think about gallbladder squeezing, because that's what happens in response to this enzyme. So once you've got the gallbladder squeezing out that concentrated bile, which is really effective and good for breaking down and digesting fats, that is then going to be quite a dynamic motion of your gallbladder, which has got muscle in the walls. So that squeezes. And then it goes down all the way into the Jodi Numb. The important thing is to remember that bile is constantly going to drip down from the liver. Not all of it's going to go inside the gallbladder because the contents of the volume of the gallbladder is only about kind of 50 to 100 mils. There's not much space, and the amount of bio that you make in a day can be anywhere from 750 mils to a liter and a half. So that was quite a volume. So of course it's not going to fit inside the gallbladder. It will consent, continually trickle down and essentially, when you are anytime. If you've ever been unwell with something like gastritis or a vomiting illness, and you find that your your stomach's empty and you're just bringing up bile. That's why, because you've constantly got filed trickling down and it's always going to be sitting in that part of your g d. Um, when you're not eating the important thing about the gallbladder. I've told you that it concentrates bile, and it's also going to help you to digest your fats better. But it's an organ that we can live without, and that's really important to bear in mind for the rest of the presentation. The last little part of the image is where the liver becomes quite furious because the gallbladder has been not just concentrating bio, but it's actually started to make some stones, and we'll talk about why and how the gallbladder can make stones. But bear in mind that function of concentrating the bio from the liver and thinking about precipitation and the formation of solid matter. All right, you can go on to the next slide, so a couple of definitions And for those of you that are still very much preclinical, a wee bit of epidemiology, um, Colazal a thigh assis is there's a lot of words involving the gallbladder and Goldstone's that can make me trip over my words, but cholelithiasis is the first one, and that basically means gallstones within the gallbladder. So cola, again referring to gallbladder and lift, is I think it's Greek. Someone can correct me if I'm wrong, certainly Greek or Latin for stone. So try and remember how words breakdown, because that's gonna allow you to remember the definitions of them. So we've got gallstones within the gallbladder, and then the word that really tests me at seven o'clock on a Wednesday is choledochal a thigh Asus trying to say that five times fast choledochal, which refers to the bile duct and lithiasis. Of course, we know stones so that stones within the bile duct there can be stones with in any part of the bile ducts, even those up in the liver, those ones down the most important one, the common bile duct. And that is going to be important to think about when we consider symptoms. But the most most part, we'll be considering gall stones within the common bile duct. When I just say build up when we think about what gallstones are actually made of. So remember that I got you to think about precipitation again. That's taking that's taking me back to my chemistry or biology classes. So when the gallbladder is busy concentrating and removing the water component of bile, it's actually quite easy to think how they can form stones. Because if you've got that solid matter coming together, you can either have kind of sludgy bile. Or you can have stones being formed and what can actually precipitate gallstone formation. More so is if you've already got kind of small, crystalline structures inside the bile, and a gallbladder just just doesn't move properly. So Hypo Mobility is another factor for those people that are more likely to form stones. And there's different scans that we can do that can tell you about the mobility of your gallbladder and something called a Hida scan that I don't talk about later on. But you can look up if you're interested, the prevalence of gallstones. So when I first started learning about gallstones and treating patient with gallstones, the thing that really struck me is that there's 10 to 15% of adults in, certainly in the UK. But as I looked further, it's the US and of Europe as well. A 10 to 15% of adults will have gallstones, but most of them have no symptoms, and you wouldn't know walking past in the street or if they're in hospital for another reason. If you're not scanning their tummy, then you're probably not going to know about it. But of course, there will be a percentage of people that are symptomatic, and I think that's where it gets quite interesting, because then the disease pattern is quite variable for people. If you come in with an episode of what we call biliary colic, so that's pain from gallstones. Without any complications, you've got about a one in two chance of having another episode of biliary colic within the year. So that can be quite an important thing for patient's to think about if they know that they've got 50% chance of potentially ending up back in hospital with that similar pain, yes, it will go away, and we'll talk about what biliary colic is like for patient's. But then underneath that you can see that 3% or there's a 3% chance of having complications of gallstones. And as you'll learn later tonight, these complications can be really quite severe, and they can make patient's very unwell. So when we come across patient's with gallstones who have had pain to biliary colic, it's really important for us to have a conversation about these complications that might arise. And how we how we navigate that. Do we do something about it? Okay, next slide, please. So you might be thinking, Well, can I do anything to stop me forming gallstones? And that's often what patients' will say. Have I done something wrong? The answer is usually no. There are a couple of things that we can we can avoid, but things like increasing age, your gender in your family history. These things are not within your control. You'll see There you might have been able to guess what a few of them were. Um, we have There's various genetic mutations. I haven't gone into those because you don't need to know them at this stage. And hopefully I don't ever need to know them at my stage. But there are some things that you're not in control of. Um, if you have particular diseases and so ones like Crone's where you might have disease at the terminal ileum, you might have to have part of your bill resected that can all increase the risk of you having gallstones. There's quite complicated reasons why in each of those, so I don't want you to get too bogged down in that. But there's important things that happen at the terminal ileum, and that is the resort option of bio salt. So there's lots out there about the proportion of bio salts in the system and in your bile that will either, um, cause you to have gallstones or not. There are various problems that patient's can have, such as haemoglobinopathy. So that's when you get various different kind of variants of hemoglobin, and some are more likely to break down releasing the him compound. And that is where your your belly ribbon pigments come from. Different ethnicities are more at risk as well. A couple of ones that were quite interesting to me were once of rapid weight loss, so that's quite important if you're taking history for lots of different reasons. But it can be relevant in gallstone disease or and something that some of you might not have heard of yet is total parenteral nutrition. So that is a way that we can feed patient's with, uh, nutritious fluid that we put through their veins when they've been very unwell. So it's important to think that we can actually induce someone to have gallstones by doing certain things that are looking after them. So TPN is something to be mindful of various medications as well. Um, I don't think there's anything you don't need to know which medications cause gallstones, but just being mindful that there's lots of different things here. Some are variable, some can be reduced, but a lot of them there are totally out of the patient's ability to impact, so you can click on to the next slide. So we'll think about how gallstones are formed in the different type of stones that you can get. So I don't want you to get too bogged down here because this is certainly not anything I really needed to know. But it's about it's just being mindful of the different types of gallstones you can have that might come about with different diseases. So the most common ones we come across our cholesterol stones, so you might be thinking, well, a spotted metabolic disease are spotted diabetes and obesity up there as strong risk factors. Well, those will be patient's who have increased circulating cholesterol. So it's no wonder that cholesterol stones are more common in these patient's. And what happens is bio becomes saturated with that excess cholesterol, so it kind of gets stuck in the liver. The bio becomes saturated with it, and it soaks it up. Patient's who have cholesterol stones typically have a kind of less mobile gallbladder's that hypo mobility we've talked about, and there's a very complex process as well. That's involved in Bible called Nucleation again. I put it there for those of you that are super interested in it. But I have never been asked about this. But it's there if you read up about gallstones, so that is another reason why you would be more likely to form these cholesterol stones. You can also get some A a variant of stone called black pigmented stones. Now this is quite an interesting one and one to be mindful of, because those diseases that I mentioned which affect the ilium or human globin opathy zor hemolytic anemia. Those are ones where patients typically present with black pigmented stones. So this is not impossible from showing up in M. C. Q. S. Um, I do remember getting questions about black pigmented stones in my finals exams. Probably one or two cystic fibrosis. Another one again. I've I've never seen this in a cystic fibrosis patient, but the buzz words are there. It might appear in an M. C. Q. Brown pigmented stones are actually less commonly seen, but more typically where there has been a period of Stasis of the gallbladder. So that can be during prolonged periods of fasting when a patient is unwell in the ICU, or where there is significant infection as well. So I've talked a little bit about the various different stones you can get. That path of physiology is important as well, and we're going to talk about these and cover these in our cases. But I'm going to mention them just now just so you can start to think about them. So gallstones, As I've told you, the vast majority of people with gallstones will have no idea they've got them, and they will never have symptoms from them. But for those kind of 15 20% of patient's with gallstones remembering, that's 10 15% of the population and 20% of them. They can have any number of these problems that are listed in the green box. The most common and nonserious one is biliary colic, so colic is a type of pain, really, and it refers to a waxing and waning pain, something that comes and goes, and you can have colic in various different places. But biliary colic is referring to pain from within the biliary tree when there are stones or within the gallbladder, when there's stones, thinking about what biliary colic actually means. Well, if I've told you that your gallbladder is squeezing every time you have a fatty meal, imagine there's all of a sudden sharp pebbles inside your gallbladder and how unpleasant that would be for a muscle to contract around those. So that's the pain that patient's get from biliary colic. It typically lasts about 44 hours maximum, and it comes on about half an hour to an hour after a meal. It doesn't always have to be an obviously fatty meal. Some patient's have got different trigger foods that fats are the most common cause. Hillary Colic, as I say, should go away within a few hours and is usually, though it's quite severe for patient's, and it can sometimes bring them to hospital. It will be self terminating, and they will feel much better afterwards. They can sometimes feel a bit squeamish, and sometimes they can vomit with it. It's often due to the pain, but they shouldn't have any Other features, such as fever or prolonged vomiting or anything like that, and they're pain shouldn't radiate anywhere else. The next word on that list is colecystitis, so we'll remember that coal assist refers to the gallbladder and itis of anything means inflammation. So we've got a gallbladder in from inflammation, and that is the next step up. Really. So once a patient has gallstones there, then at more risk of having colecystitis and that really refers to the gallbladder will becoming inflamed, painful and usually there's an infection there. Almost all patient's who have colecystitis will have gallstones, but it is possible for you to have what's called an acalculous cholecystitis, and that is referring to again. Those patient's who have been in the I See you have been very unwell, and it's more Stasis of bio rather than stones that are causing the problem Colecystitis is something that we need to know about as surgeons because it's not going to get better by itself. And patient's can become very sick quite quickly. If we miss it so typical, things will be pain. It may be similar to biliary colic. It's in that right upper quadrant of the abdomen. They will often say that the pain is radiating. It might radiate to the back. It is usually kind of grumbled on. And then it's become very severe and sustained, and they can often become sick or vomit or certainly become off their food. And having a fever is usually consistent with a presentation. As I say, this is not something that's going to resolve itself. It typically requires antibiotics for us to get, get it under control, and sometimes patient's won't set with antibiotics. We need to consider taking their gallbladder out in order to get them better. A few things down at the bottom there is Maurizi syndrome. This is, um, I can say this because I'm a I'm alumni of Edinburgh. Edinburgh loves an eponymous syndrome, so this is one to listen out for. I've come across it several times as a trainee and this is where you can have a gallstone that is either inside the gallbladder or just at the gallbladder neck that causes impingement of the bile duct blow. And even though it's still within the walls of the gallbladder, it can cause an obstruction from the outside. We call that an extrinsic obstruction, and it's almost as if you were to pinch a tube from the outside and it's gonna it's gonna stop that bile flowing. So Maurizi syndrome is a way where you can have a blockage, but actually there's nothing inside the tube. It's pressure from outside, and it's usually the HPB team that have to help us with those cases because they're not straightforward acute Collinge itis. So that is a condition that I'm very anxious of because patient's are very sick typically, and this is where similar to colecystitis. It's inflammation and infection, but of the common bile duct, usually, and this is where there's been a blockage, usually a stone that's come out of the gallbladder and got stuck down usually the bottom of that tube that I showed you, and it started to form a nasty infection with an obstruction, and that is a really serious condition that we have to act quickly on with antibiotics and a procedure that clears the stone. And I'll tell you about that a bit later on the last one that I'll mention here is a cola cysto enteric fistula. Now what the heck is that? Well, that is when you have got inflammation from the gallbladder. That's maybe been on a more chronic pattern, and it's broken down the wall of the gallbladder, and it's allowed to kind of entered into the adjacent bowel loop that's there. And that's usually Judean. Um, so you can have this little fistula, which is an abnormal connection between two hollow, viscous is and that then allows the gallbladder to communicate directly with the bowel. It's usually not an emergency thing. It would need a big operation to fix, but that's something that can happen as a result of gall stone gall stones causing inflammation. Okay, I'm going to leave the or two. They're just because they're a little bit kind of lesser known. If we've got time at the end, I can mention them. So if you click on to the next slide, so for those of you that are in clinical years, it's really important to be able to take a good history of patient's who have come in with a gallstone related problems. So we're going to have to think about what biliary pain actually looks like. And I'm hoping the one in the audience is a very experienced Billary pain. But certainly a lot of doctors have, and it is described a really severe pain, and you'll see that when you see patient's present, because they really look distressed until the pain settles down. So it's typically experienced in the right upper quadrant, but sometimes it can be felt a little bit more epigastric. So that's in the kind of center just underneath the carina of the lungs, Really. So just in between the right and left side of your rib cage, it's described as an episodic pain, so it might come and go, and then it might come back weeks or months or years later. It can sometimes radiate. It's not typical when it's just gallstones, but sometimes patient's say that the right shoulder might be a bit sore or they might have some pain in the back, and that can be typically because of irritation of the diaphragm, and that's causing that kind of right shoulder tip discomfort. You can get that with a lot of things, but with gallstones, that is something that's recognized. Some people say it lasts about 15 to 20 minutes, but others can have several hours of pain. And it's those patient's that sometimes present to the emergency room because they have been worried the pain hasn't settled. And then all of a sudden you come down having seen you come down to see them after A and E have phoned you, and the patient's very comfortable. And you think, Well, I think this is probably the little colic because if they were very sore an hour ago and now they're fine any serious pains usually shouldn't get better themselves. I've said about 30 minutes to an hour after they eat, and it might be something fatty or it might not be something obviously fatty. But just be mindful of that duration and always ask the patient what they've had to eat. As I say, sometimes they'll feel a bit sick or they might actually vomit. If it's gallstones causing a biliary colic. It shouldn't be, uh, recurrent vomiting and it should maybe just be one or two discrete vomits. It shouldn't be a continuous vomiting illness, something to be mindful of if you have someone who's had pain for more than even more than four hours. But I've said eight here if they have a fever or tenderness in their abdomen. This is more suggestive of inflammation of the gallbladder or infection of the gallbladder, called a cuticle cystitis. And we have to intervene there because these patient's need to at least have antibiotics and be seen by the surgical team. There are some risk factors that you can identify, and we've talked about those. Those are the strong risk factors, a lot of them you'll be able to tell from the end of the bed. But be mindful and always ask about family history. Often, you'll find that there is a family history of gallstones in the family. You'll be less likely to pick up on any genetic abnormalities unless someone tells you. But being mindful of other things, like, um, also about Crohn's disease or any previous surgeries, any rapid weight loss. Just keep those risk factors in your head and be sure to ask about them in your systemic inquiry, you might find that some other non specific features. And actually a lot of the time. My job is trying to delineate from a lot of non specific features because surgical patient's don't always present as textbook cases. Sometimes they can experience bloating, and they can become either quite windy up the way or down the way with lots of excess gas. And sometimes they can have a bit of heartburn as well. Um, things that I've mentioned in that other little green box. So the pain or the tenderness in the right upper quadrant, uh, right upper quadrant or the epigastrium is quite common, um, to gallstone disease. But don't be. Don't forget. It can be a lot of other things as well. The right upper quadrant could be, uh, pain from the pleural cavity. It could be bowel. It could be the right kidney. There's lots of important anatomy there, so remember where you are and don't become too. They don't have don't have tunnel vision just because you're in a surgical unit and you think it's going to be a surgical problem. Be mindful of other things and always listen to your lung bases and also consider renal angle tenderness. Things like that. If you've got someone who has a fever, as I say, or a particular sign called Murphy's Sign, you might have heard of this. When people talk about examining people with gallstones, Murphy's sign can't quite show it to you. But you're basically moving your hand up the right side of the patient's abdomen, and you move it gently with every you move it up in increments every time they take a deep breath in, and what you're ultimately doing is catching their gallbladder in between your right hand and they're flattening diaphragm. And that squeezes the gallbladder. And that kind of gives them what's called an inspiratory catch because they all of a sudden experienced pain and they can't breathe in anymore. So that's what we call Murphy's sign. What you could probably do is if that, because it's quite difficult to explain, is look it up on YouTube and you should probably get a good example of a Murphy sign there. You shouldn't get Murphy's sign positive in Patient's with Gallstones, and we see Murphy sign is positive when they get that inspiratory catch and experience pain when they're doing that inspiration with someone with straightforward gallstones. They might be sore over there, right upper quadrant, but they shouldn't have that positive. Murphy's sign. Okay, next slide, please. So onto the stuff that I find really interesting and that's how we investigate gallstones. There's lots of different things that you can do and you can see here. There's a number of things that include imaging or blood tests. I'm going to focus this mostly as an f Y one in one FY. One doctor will be able to do because that's what you guys will be either in a year or two or a few years. And it's important to know that you are able to do lots of things as an F Y one. Lots of helpful things, even though it might be your first job in a surgical unit. There is so many things that you can do, but it's about becoming equipped with the right tools, and you're building your tool kits blood tests. So I'm sure you can all do blood tests, and if you can and you're very busy, you'll have nursing staff and auxiliaries who are able to help you. But knowing which blood tests to get to the important things. First one, there is liver function tests. Now the funny thing about liver function tests as I don't ever really look at them to tell me about the liver. I look at them to tell me about the biliary tree and the gallbladder. So if someone has got simple biliary colic, their blood should be normal, because when we start to see abnormal liver function, test is when we have either an obstruction in the biliary tree. And we call that an obstructive derangement in liver function test. And the other thing that you'll remember from your medical school teaching is that you can have hepatocellular damage, and that can give you a hepatitic pattern of liver function test arrangement. I'm not going to talk about that. I will refer to the obstructive things and you'll see in the cases which of the LFTs will be abnormal in cases of obstruction, and I've actually mentioned a few of them there. I've said obstructing choledochal with Isis can cause rises in two of your LFTs, so the A LP and your G T. Don't ask me to see the full names of those, and we're gonna use abbreviated terms tonight because my my ra memory and recall of these is not great. E l p and G g t. Those are important ones to think about Choledocholithiasis issue. Hopefully remember is when we have a gallstone trapped in the common bile duct. Now you're doing one set of blood. LFTs doesn't tell us that there is still a gallstone there, or whether it's causing a blockage entirely. It's just going to give us an idea. It's the trend that's more important. So it's important to get some liver function tests when the patient presents and if they're coming into hospital, your then going to get another set of bloods, probably the preceding day, to see how things are, especially if there's been abnormalities. So as I say, their trends are much more helpful than one off readings. We want to do a full blood count because that's going to tell us a number of things about the patient. But the thing that I'm interested in is the white blood cell count. If that's elevated, this is less likely to be a case of biliary colic. Remember that shouldn't involve infection or inflammation. But what does involve infection and inflammation is acute cholecystitis or cholangitis or pancreatitis. We haven't talked about pancreatitis yet, but we will. Amylase is another blood test I want to do. And that's where pancreatitis comes in. Because that is going to be our biochemical test to help us diagnose pancreatitis. And for those that are preclinical pancreatitis is if you break the word up. Pancreas, an itis inflammation, inflammation of the pancreas. Gallstones can cause that one of the most common causes of pancreatitis and the other one is alcohol. The initial imaging that you can do as well as an F Y. One. You can't do an ultrasound by yourself, but you can order one, and you can put in a request to make sure that you tell the radiologist we're looking for gallstones here. I think they have either got biliary colic. We've got coolest. It's up colecystitis. These are all things that are within the remit of fy one. Now, if you look over to the image here, I'm not able to wiggle. You should be able to see a little black pouch that sits just in the kind of just off to the center at the right hand side on the upper part of the image, and you can see four little bright white dots inside it so that black sack is the gallbladder. You can see the kind of white wall that's around it. That's the wall of the gallbladder and the read the little white things inside of the stones. Underneath that, can you see a big black shadow? That is what we get when there's stones or solid material, because it causes an echogenic shadowing. So the ultrasounds are not able to permeate through that, and you end up getting a distorted image or a shadow. So that tells us those are gallstones inside the gallbladder. Okay, next slide, please. There's some further imaging that we can do as, um as doctors. Now, this is where you step out of the FY one remits. But it's important that you know about these scans because we might ask you to book them, and it's important that you know why we're getting them, what we're going to see from them. So if you've done an ultra ultrasound of a patient and it says yes, there's gallstones there, and we've just seen an example of that. But they might say there's other things. There might be some thickening of the gallbladder wall, which suggests that there's inflammation. There might be some dilatation of the biliary tree, which is suggesting that there is a blockage. So if you think of it becoming distended, it's because it's trying to get past a blockage that's downstream. If we see things like that. And if there's obstructive LFTs on the Bloods, we might then book a scan called an M R C P. And again, I always get a mix up the name of this. It's magnetic. Uh, was it? It's basically an MRI, can never remember what it actually stands for and get it exactly right. But it's an MRI scan, which is looking at the biliary tree, pancreas and all of that Billary anatomy that we looked at earlier on and what you can actually see down below. There is an image which looks quite like what we were looking at on the cartoon, but this is actually an MRI generated picture and to be extra kind of labeled everything so you can see up the top in black is the liver. We can see the bile ducts coming down. We can see the gallbladder, and then you can see a trip coming down towards the bowel. And that is essentially coming down into the Jodi Numb. And you can't see the entire Judy Judy, Um, because not everything shows up brilliantly. But what we're looking for here is any blockage in that the common bile duct or otherwise. And if we did see a blockage, it would show up as a little black pebble that's inside. And that's because we're not able to see the contrast that the patient has within the bile duct because it's been blocked. There's a little stone or sludge that's inside there. So we might do that. Um, if there's any suggestion for the ultrasound or the liver function tests, the very important thing as an F Y. One or anybody is to make sure that a patient is safe to have an MRI. So there's a safety checklist that goes through for anyone that's requesting it, and it's very important. Remember, patient's have pacemakers or implantable defibrillators or cochlear implants. All of those are contraindications to MRI scans will be very mindful of that. We can do other things. So if the patient cannot have an MRI because they've got implanted metal in the body somewhere, we can do an ultrasound by, uh, endoscopy. And basically, what happens there is they have an endoscope passed down, goes into the duodenum, and then they pass a very small ultrasound probe that can allow you to look from the inside using an ultrasound. And it's a much better quality ultrasound than you get going from the trans abdominal route when you're going outside in the tummy. So that's something we reserved for those patients that can't have an MRI. If someone's very unwell when they come in, or if there's other diseases that are suspected more than gallstone disease, we might do an abdominal CT scan. And again, this isn't something that an f Y one is going to be deciding on. But you will often be asked to help book a scan for a patient. And this is usually what we're considering non Billary problems, but where we can also look and get some idea of whether there is, um whether it there is gold student disease. Okay, next slide, please. So I've just talked about we might scan a patient with a CT scan if there's other diseases going on. So it's important to think. What are those other diseases that we can get when someone has what sounds like Billary pain? So something that you can remember all of my teaching and peptic ulcer disease as a student. So you I can remember. I appreciate you guys probably know a lot about it, but that can present quite similarly with the kind of pain around eating or just before and and pain in a similar place. If you think where the Judean Um is, it's around kind of where the gallbladder is and even like the lower stomach as well. Gallbladder cancer is quite a rare thing, but we have seen it a few times, and it can present quite similarly where there's not stones that you get colecystitis. I've talked about Acalculous Cholecystitis. So think of the unwell patient in the ICU who hasn't been eating as a Hypo Mobile gallbladder and has formed a kind of thickened Bible and ends up the cola cystitis. You can have polyps inside the gallbladder, and that is basically where you got little growths like polyps you might find in the bowel or else elsewhere in the body. But those polyps can give you pain, as the gallstones can, so it can present Very similarly. You can have a pancreatitis, which is caused by other things than gallstones. And that can be. It's a upper abdominal pain with vomiting and nausea, so that all sounds quite Billary. But those can be other things we encounter. And for those of you that remember what I mentioned at the very beginning with the anatomy, there's a little sphincter at the bottom of the common bile duct, and that is going to help regulate by opening passed into the bowel. So if you've got dysfunction of that sphincter, you can also experience Billary pain. So these are just things to keep in the back of your head when you're seeing patient's with Hillary pain. These are definitely and some of them are less common. But peptic ulcer disease is very common, and and pancreas pancreatitis is quite common. So keep some of these in your head because it might not be a straightforward case of biliary colic. It could be any of these things as well. Okay, next slide, please. Okay, we're nearly getting onto the cases. So we're going to have a think about how we manage gallstone disease. There's two main patient groups. There are those patient's who have got gallstones and no symptoms who we might have picked up as having gallstones. On another scan we were doing for another reason. We call that an incidental finding, and I'll jump to that at the bottom versus asymptomatic gallstone. So we know there there. But the patient hasn't got any symptoms of gallstones. We don't treat them unless there is a risk of patient's having a gallbladder cancer. Now that could be if there's polyps. There's a definite increased risk of gallbladder cancer, so we would counsel the patient on that and suggest doing removal of the gallbladder called the Cholecystectomy. There can be patient's who are more at risk of having complications of gallstones and that an example that's patient's with sickle cell disease where they have essentially, there are more risk of dehydration and complications of that as well, so there are definitely some patient's who, once we know they have gallstones. We do recommend taking their gallbladder out because we know from the past that they are growing open evidence that there are more risk of complications coming to the top group. So patient's with what we call symptomatic gallstones, and that can vary from someone who's had one episode of biliary pain or someone who's had a gallstone pancreatitis. There's different things we can offer them in the very immediate, um, management. We need to get on top of the pain. So we use the W H O pain ladder. We use adjuncts to that, such as NSAID is if the patient's can take them or we use antispasmodics to help the spasm and gallbladder. Some patient's choose not to have an operation, and so analgesics might be the best thing for them that they can have more long term and just avoidance of fatty foods. And sometimes losing weight can help as well. Most patient's who've had an episode of biliary colic or a more serious complication will opt for having their gallbladder removed, because once we take the gallbladder away, the chance they're certainly not going to have true biliary colic anymore, even though they can still form bile stones in the biliary tree. They won't have that same pain again, and we can manage their symptoms and reduce the risk of from having gallstone, pancreatitis, all those different things by taking the gallbladder out, and most people will opt for that. How do we do that? Well, you can see on the right hand side a nice example of keyhole surgery to remove the gallbladder. So basically that means that we use very small cuts, and you can see there's 1234 cuts that we make in the tummy, one at the bottom for the camera that goes through the tummy button. And we use tiny instruments on long extended poles to take the surge of the gallbladder out, and patient's can actually come in and have that done in a day and then go home. After a little bit of observation. They need about 4 to 6 weeks to recover. But most will recover without any problems, and it can be a reasonably straightforward procedure to do, Um, but no operation is risk free. Let's move on to the next slide. Okay, we've talked about a few of these, so I'm not going to labor them too much because I'm quite keen to get into the case is to get you guys thinking complications of gallstones we've mentioned, and we need to think about how we treat these now. So if you're someone who has got a stone, a gallstone in your common bile duct. But we have picked this up, Incidentally, your well, you've got no symptoms. We have to think about that because it's not quite the same as finding someone with gallstones who've got no symptoms. This is a stone that's inside the bile duct, and chances are it might not clear, and it might stay there. And then the longer it stays there, even though they've not got problems now, the chances of them developing problems and symptoms is much higher, and they can be very severe. So what we would offer these patient's and important to mention patient's who are otherwise fit and able to withstand an operation. We would offer to do a keyhole operation to remove the gallbladder and clear the stone out the bile duct at the same time, so it's different to patient's with gallstones and no symptoms. That's the really important thing to think about acute cholecystitis Well, these patient's typically come in quite unwell. We have to resuscitate them so that's using an A T E approach that involves oxygen fluids, um, taking off bloods, thinking about antibiotics and cultures. Often it's sepsis. Six, because they present septic sometimes. But once we've got all of that done, we then have to think about getting the gallbladder out at some stage. And we call that a hot cholecystectomy if we do it when the patient's on the same admission. But sometimes once we've got them better with the course of antibiotics and we're able to let them go home again, we let everything settle down. We let them recover, and they can come back for what we call a cold cholecystectomy. And that's where we let all the inflammation settle. And they come in for a cholecystectomy as a day case patient. And that happens all the time. Acute cholangitis. As I said, this is the one that still frightens me. That's a stone trapped in the goal. The bile duct. Usually that's caused a bad infection, and you can see a picture of that over that little image. You can see a stone trapped in the bile duct. It's become a bit distended, so what can happen is there you've got bacteria from the bowel cause they're all contentedly connected. And if you've got an obstruction with bacteria, what happens is it multiplies quickly, and the patient can be very quickly become unwell with sepsis. So you have to resuscitate these patient's. They need what I've said. Triple therapy antibiotics. If you've not heard of triple therapy, those are the three antibiotics that we use for intra abdominal problems or infections. And that's what we called amoxicillin, gentamicin and metronidazol. Don't worry too much as an undergrad, but it's certainly something to know as an f Y doctor, because you'll be prescribing them a lot on a surgical ward. We then have to get rid of that blockage, and we do that by a procedure called an ercp, which is an endoscopy, which then goes up so it comes into the down the esophagus into the stomach into the Jodi Numb and then passes small instruments up that bile duct to fetch the stone. That's a C B. That's, uh, ercp gallstone pancreatitis. So we treat pancreatitis with what we call supportive treatment, so that's fluids and pain relief and keeping a good close eye on the patient. But then if we know that gallstones have caused it, could we do an ultrasound to see if they're there? We will then offer the patient a keyhole and are laparoscopic cholecystectomy once they've recovered. Because what can happen is those gallstones can cause the pancreatitis again. And you can see there's a little image just to remind you what that is. So inflammation of the pancreas, gall stones and alcohol is the most common causes. And then you can see where the pain is. It's an epigastric pain that they complain of. Okay, next slide, please. Right. We're into the cases. So I'm going to open up the chat box, if I can see it. And I would Oh, lovely. Thank you very much. Is male for putting what the m r. C p stood for again. It's the cholangiopancreatography I can never quite remember. Okay, so please use the chat box to give me your ideas. There is a usually no wrong answers here, so don't don't feel stressed. This is, uh, no judgment. And I'm just looking for you to give some ideas. And if you answer, then you're doing very well. So first patient case, you're going to pretend to be the FY one in the surgical observation unit, your patient is a 55 year old lady who has come in with a sudden onset pain in the right upper quadrant of the abdomen. Just looking at the end of the bed, you can see that she's sweaty and she's very uncomfortable. The nurse has kindly done some observations for you. The heart rate is 100. The BP is 100 and 15 systolic. The respiratory rate is 16 and she's breathing in air at 97% stats. The temperature is 37. Question I put here is How will you proceed and what I'm looking for There is. How do you want to assess this patient? Is this someone you're worried about? Or is this someone that you think? Yeah, I can do a history and examination here. What we want to do? Yep. Good. So we want to be thinking about history. I agree with you because I think she sounds well enough that I don't need to do a full a two e here, So I think that you can you can get right into taking a history. Let's go into the next slide and see what happens next. Okay, so, yeah, she was definitely well enough to not have to run in and do a quick 80. She's able to give you some history and says that the pain came on about 30 minutes after eating her dinner. She's feeling it a wee bit in her right shoulder, she says. It's maybe going through to the back a bit, but it's coming and going in a kind of wax and waning motion. She's never had it before, and she says it's eight out of 10, so it's really bad pain for her, and she feels a bit sick. But she hasn't had any vomiting, and she's got a little bit of past medical history, but nothing too concerning. She's got bit of hypertension. She's got a bit of central obesity, and she's had a C section before. Um, she's on something for her. Blood pressure's on Ramipril, and she's got no allergies to anything. There's nothing in the family history. She has got admin role, um, her works independent. She occasionally drinks but doesn't have a heavy alcohol history, and she smokes five cigarettes a day. Always remember your ice. She doesn't know what's causing it, but she says, Oh, maybe it was the fish and chips. I just did it for my dinner. So talk to me about examining the patient. What were you looking for? Whether it's signs or what do you think might come up on this patient's examination? Good. I like the idea of general inspection. So we're thinking about from the end of the bed, Does the patient look unwell, or do they look okay? Is there any jaundice? Good. We're thinking about gallstones. And what might cause jaundice? Absolutely. So she's not jaundice in this case. Um, and then we've got some. Yeah, the Abdo exam. So agreed. I think a good abdominal examination is really important here. We're gonna be looking for areas of tenderness, so she might be a bit tender in the right upper quadrant and guarding. That's a really good one. So we can have voluntary or involuntary guarding. The one that I worry about is in voluntary guarding, because that suggests that there is peritonitis, right? Upper quadrant tenderness. Yep. Exactly thinking about Murphy's sign. That's very good. Now remind us what both sign is because this is not one that I keep in my head. Very good. I thought you were going to type it, so I've I've typed in. So it's when patient's have hyper. They're hypersensitive when they're being touched lightly on there, right Lower scapular region. I've never done this clinically, but it's a very good one to know about. Four exams and M. C. Q. S. A very good point. Excellent. Good. Those are all the things that I had on my list. Let's go to the next slide and see what happens next So you can see from examining the patient. They've got an elevated B M I. They look like they're in pain and she's clutching the right side of her abdomen. She's not got any jaundice, but you think she looks a wee bit pale. Her abdomen has got tenderness in the right upper quadrant. Her belly doesn't have any distention. You do a couple of bedside tests, we do a urine dip and it's clear and the blood sugar is normal. How would you guys like to investigate the patient? What tests will you order as the fy one? So we talked about to kind of mean groups who talked about kind of biochemical hematology things. And we also talked about imaging. Yep, Good. I agree with these thoughts, so we want to look wanted a full blood count. We want to get a white cell count. Yep. Anomalies. Excellent. Always important to remember Liver function tests. Excellent. I really like that Lara has said Liapis, because that is something that you need teaches you. But then we actually don't get Lipes. We get AM Elise. Why do we get Emily's? Because it's cheaper, even though it's not as good. So lie Pays is really gold standard because in pancreatitis it will shoot up very high, and then it will stay high for about five days. So it's very easy to tell if a patient had a pancreatitis. Families will peak and then drop, and it's hard for us because we sometimes miss the peak. So that's a really good point. Ultrasound. Yes, I agree. I think we need to do an ultrasound of this patient's abdomen, and we might need to do an MRC P afterwards, so we'll keep that in the back of our minds. Okay, next slide. Let's see what then happens. Okay, so we've done some liver function tests. They're normal. We've got a normal white cell count, and I threw in a crps C reactive protein there for you, which also looks at inflammation. That's normal, too. So the ultrasound comes back, and it shows that there's large mobile calculi. That means a big skull stone within another wise normal gallbladder. So there's no suggestion of thickening or inflammation of the gallbladder wall. So that's good. There's no biliary dilatation in the biliary tree. We can't see the pancreas because there's a bit of bowel gas over it. But that's okay. There's no other features of pancreatitis. So what's our diagnosis here? And how will we treat this patient? Excellent. Good. Cool Earth, Isis, which is gallstones? Are these symptomatically symptomatic? And if they're symptomatic, what do we call this? This presentation? Yep. Symptomatic. So the patient has had an episode of biliary colic. What do we do for that? Yep. Good. I like the way you're thinking, Lucas. I would definitely have a chat to the patient about the risks of having further Billary Billary pain attacks. I would also say Well, we've got about 3% chance of having a serious complication So what we would typically do is offer this patient, uh, a lab calling, and sometimes they won't have a think about it. They want to see us in clinic. That's okay, too. And we can we can give them some information leaflets, but yeah, I agree. I think, uh, lap call is not a bad idea for someone who's had biliary colic. Who doesn't want it to happen again. And there's actually evidence coming out now to say that we should be a patient. Come in, come in to hospital with pain. We should be offering them a lap collie if they if they're otherwise quite fit and well, good. Okay. What's really important as well, for this patient is giving them pain relief. So we get quite excited about operations sometimes. But don't forget analgesia, because that's what they're going to thank you for. First, let's move on to the next case. I think there is another one. Oh, no, It was just a quick reminder of what we do, So yeah, we we give some analgesia we used to hate the w H O pain ladder. We gave some NSAID because she was able to have them and we've offered a lap. Coli and the patient was happy to talk about a cholecystectomy and your registrar then went away and got a theater slot and patient pain settled. They're able to go home, and they'll get information about their surgery dates in due course. Excellent. Yep, Good ideas There is. Well, that's a nice summary. Okay, let's go into patient case to So you're still there by one and you're working in the surgical admission's. It's overnight and the nurses called you to the bedside of, uh, older patient who's mail the committee Aleve a day and has become quite confused. And she's really worried about him. She says. He's 80 years old. Mr. J initially come in with right upper quadrant pain and fever, but now he's really quite confused. He's not orientated to time, place or person. His observations are a wee bit abnormal. His heart rate's up a bit, so his BP is a bit on the low side, working a bit harder with his breathing. SATs aren't as good as they were when they come in, and he looks like he's about to spike a fever. So this this patient is pleasantly confused, but he's not really able to give you a history. So what? What would you do next? Where might you get some information from and what's important to to do for this patient in terms of assessment? Yep, that's that's good. You're gonna information. Gather you're going to speak to the nurse is what do they know and what's in the car decks? The news Exactly. Yep, Relatives might be there. I agree as well. We need to resuscitate this patient because their observations are quite alarming, aren't they? So we'll get a wee bit of information from the notes and the news chart and people around, and whether it's nurses are relatives get kind of quick history. But we need to do an 80 for this patient, don't we? So let's go into the next slide and see what happens. So the nurse is able to remember from the handover that he's got gallstones. We knew that, but he's awaiting a scan tomorrow, but she can't really remember what type of scan it is, but he's normally independent at home, so this is a real change from what he's normally like, and he's got past medical history with gallstones are there. He's got a bit of COPD. He's got some ischemic heart disease and you say, Well, look, I'm going to do an 80 of the patient and the nurse is going to help you because examining a confused patient can be a real tricky thing. So what things are we looking specifically for in clinical examination? What things might you notice from the end of the bed and then thinking about the abdominal examination? What do we think we might find? Yep, I agree with you. I'm going to be worried that this patient might be John's ist mhm. Anything else thinking about how his belly might examine, or even what people with jaundice might also have? Okay, that's a Yeah, it's not. Not a bad suggestion. There could be ascites if there was jaundice from, uh, kind of from a hepatic problem. Yep, so we wouldn't be able to see the obstruction necessarily. But there will be features of a biliary obstruction that will see that jaundice patient's with jaundice can also be quite itchy. They can complain of pruritis. Um, if you click on to the next slide, we'll see more about what happens to him. So yeah, he's He's very jaundiced. And you can see the sclera of his eyes or yellow. So he's got scleral icterus. He's got yellow of the sclera. He's itching his arms, the net and legs. He's conscious, but he's quite confused and you feel his arm and he feels hot and sweaty and you're starting to gently press his belly and examine him. But he's quite distressed when you do that. So it's quite clear that he's in pain and his temperature is actually now come back at 38 9. So he's got quite a high fever. So he's had some investigations already. Bear in mind this patient come in earlier in the day. What would you like to see from his from those initial investigations? So what would this patient had done? What are we looking for there? Yeah, excellent. See him again. We want to see what the Bloods and we want to see what this white cell count is here. Because I'm worried now that this patient's got a fever and yeah, we want to see what the LFTs are showing. Definitely getting am Elise. Um and a CRP thing is gonna be helpful. to let's click on and see what investigations he had. Good. So we've got some LFTs there now. You guys don't need to know what the normal parameters are, too. Probably tell, these are quite high. So the LP is definitely very high GTs high, a LTs even up. I think that's doubled a bilirubin of nearly 200. That's pretty high. And if someone looks jaundice, then their bilirubin is usually about 60 and that's already too high. I'm a bit worried about his white cell count is CRP. They're really elevated, and we've done a few other tests just because we're needing to make sure we keep an open mind with this. We've done a chest X ray because don't forget a fever could be coming from the pneumonia, so we've done a chest X ray was done an E C G. This was an elderly patient with the tachycardia and a low BP. It could be something cardiac, and we see that there's not anything new there. But there's a couple of things to know about this patient because they have emphysema and they've had a previous MRI in the inferior leads. But there's no acute new findings. So that's those are good things. We do have an old ultrasound report. We didn't repeat it on admission because we knew you had gallstones. But an old ultrasound says that there is small gallstones in an otherwise normal gallbladder. So we're going to ask the nurses to take some cultures now some blood cultures, because the patient has become febrile. What do you guys think might be going on here? Someone who's got known gallstones has become jaundice and unwell with what looks like sepsis. What might be happening? Good. Yep, I agree. I think this is cool, acute cholangitis. But I also agree with Lara that this is a patient whose septic they're not quite at the stage of septic shock yet because we have to treat it first to see if there's a response. But they're definitely they're trending down towards that, absolutely, but they're definitely meeting criteria for sepsis. Six. Let's move on and see so well done. Yes, acute Collinge itis. That's what we think is going on here. He's got fever. He's got pain in the right upper quadrant and jaundice, which, as Israel has said, there is shark codes triad. So that is another lovely, eponymous triad of symptoms that Edinburgh will like to teach you about. But it's important to remember, and I just remember it as cholangitis begins with a C so shark owes Triad refers to that there's lots of other triads that you'll be remembering for other conditions, but Charcot's is for cholangitis, so right upper quadrant pain, jaundice and fever. But this patient's also got two other findings, which are referring to a famous paint ads. There's confusion and hypertension. Can you tell me who's Penta? Add. This is it's someone who is also famous for when you have bad circulation in your fingers. They have this disease. Yeah, well done it. That's right, it's Reynolds. So that is Ranald pant paint. Adhere, and you'll find that in medicine there's lots of different conditions with posthumous names. So yeah, well done. That is a real worry in someone who's got a acute Collinge itis with Raynaud's Pent had. This is a very unwell patient because confusion, hypertension are basically kind of later stages of this infection. And as Lara said earlier, this is someone who is kind of looking like they're in septic shock because they're not perfusing their brain properly. That's why they've got confused. So we are looking at the patient drug chart now because we started to resuscitate them with got sepsis. Six. And we're starting to plan that you review the drug chart to find that it's only partially filled in with regular medications. But there's nothing else being prescribed yet. Oh goodness, we need to We need to think about that. What would you guys like to prescribe here and then? Can you also tell me what scan you may be booked for tomorrow? Yep, definitely. He's sore. Even though he's confused, we know that he's distressed, and pain will be making that worse. So analgesia and antibiotics very good. I agree. This is a case for triple therapy antibiotics. So those ones I mentioned earlier and it's important to make sure that patient's don't have any allergies because we have to amend them Sometimes if there's a penicillin allergy and yeah, I totally agree. I think Lara and Ismael, we definitely need to give some IV fluids and I agree a bolus of fluid and then to assess the response. That's exactly what we need to do here. What scan is he booked for tomorrow? Remember, the nurse said she couldn't quite remember the name of it. Any idea what it might have been? Think about where we're looking at where we want to look at what might be going on in the bile duct. What scan do we use for that? Yeah, excellent is an M. R C P. Let's click on and see what happened to him. There we are. So Mister J became acutely unwell during admission. You needed antibiotics or you need set to six bundle to be activated. You gave him triple therapy antibiotics to cover the biliary tree. Well done. So you got that you gave analgesia and you gave him some IV fluids. And I've said cautiously just because he had some heart disease in the background. But certainly someone like that does need a bolus of fluid. So it's an M R C p that he's awaiting, but actually, because he's become so unwell tonight, I think we need to escalate things and probably get an urgent CT scan tonight just to rule out any other problems. But it will also tell us if there is a cute cholangitis and then we can see the result down there. The CT scan confirms our suspicions of acute cholecystitis and following your excellent resuscitation of fluids, antibiotics and oxygen. He started to settle down, and then your registrar went down and arranged for the patient to be first on the list for an E. R C. P the following morning. And that's what's going to help clear that obstruction in. And that's definitively. That's definitively managing it. OK, brilliant, right? What I'm going to do is we only had one more case left, but we've gone over time quite a bit. So what I will do is I'll let Beatrice and Lucas. If you guys want to disseminate the slides out, you can definitely do that. And if there are any questions about, I think there's a pancreatitis case and there was one more. But you can email me any questions. The guys have got my email, Um, but those are ones that you can work through in groups or just yourselves as well. Thank you very much for participating in the chat so well. I was really impressed with that for eight o'clock at night. Are there any questions or Beatrice, if you've got anything that you wanted to add. That was great, Saskia. Thank you very much. Um, and I see we've just put in the feedback form as well. Um, so if you be able to fill that in, um, that would be great. Um, lecture slides should be available on there will be uploaded to medal after the event as well. So you'll be able to see the slides you've seen and the remaining cases as well. If you want to go through those. Yeah, that's fine. And I think my email will either be I think you guys have got it. So you're you're welcome to disseminate it to the rest of the group if there's any questions, but, yeah, work through those other two cases and see if you can figure them out. I'm just sorry we I ran over a little bit and didn't have time for them, but no worries. That was great. Thank you. Yeah, no bother. Um, if there's any other questions, I'll kind of hang around for, like, a minute or two guys. But thanks very much for contributing in the chat so readily that was made my job easier. No problem. Hope you enjoyed. It's always impressive when students attend things out of hours. So good job. And we'll done for Beeches and Lucas organizing it as well, especially given all the technical difficulties. They've helped me, The tech grandma, get through all Just put my email address there. You're welcome to message me. Any questions? Okay, Hopefully the other two cases are not too challenging.